Repeal and Replace and NPs: What Lies Ahead?

If primary care shortage worsens, will NPs be the answer?

The hue and cry over a shortage of primary care physicians is a familiar lament, but it reached critical volume with the expansion of Medicaid under the Affordable Care Act (ACA): more insured Americans meant an even greater need for primary care providers.

"Everyone says, due to the growth of health insurance coverage we're going to expect this huge growth in demand for primary care services. I don't know if we've seen that. And I haven't seen a study that's really done that well or that tells us has that bump occurred? What's been the size of that bump?" said Grant Martsolf, policy researcher and faculty member, Pardee Rand Graduate School.

Especially within underserved populations, the trend toward increased utilization of NPs and PAs occurred years before the ACA.

Still, some worry that this sector was invigorated largely by the downstream effects of the Medicaid expansion. "It's completely legitimate for people to be concerned in a very uncertain situation," said Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute.

The problem is, good measurements are hard to come by.

According to Arpita Chattopadhyay, branch chief of the National Center for Health Workforce Analysis, while workforce data is readily available from the Bureau of Labor Statistics, it may not measure the actual economic impact of the growth of NPs and PAs.

In workforce data, raw numbers of currently licensed NPs and PAs are counted, but a portion of them might not actually be working in the field. Utilization, the number of patient visits performed by NPs and PAs and this growth over time, is harder to measure since NP and PA productivity is sometimes buried within the physician's bill. The Center for Disease Control's National Ambulatory Medical Care Survey has only recently started asking questions about who else a patient might see apart from a physician. "In terms of utilization, nothing is readily available off the shelf," said Chattopadhyay.

Several provisions within the ACA funded programs to expand the capacity for primary care and increase expanding roles for PAs and NPs in healthcare delivery and utilization, with an emphasis on prevention and chronic care management. The law provided $11 billion to expand FQHCs, which serve mostly Medicaid patients, and funding to the National Health Service Corps for loan forgiveness for nursing graduates who work in medically underserved areas.

"There was enormous interest on the part of the Obama Health and Human Services team in thinking about ways incorporating NPs and PAs could save the government money ... several studies [were] commissioned where they estimated the cost savings for the government of enhanced use of these professionals," said Patricia (Polly) Pittman, associate professor in the Department of Health Policy and Management at George Washington University.

According to Pittman, the Medicaid expansion had a tremendous effect on utilization in Community Health Centers (CHCs) through the patient-centered medical home (PCMH) model which emphasized the hiring of multi-disciplinary treatment teams to manage medical care. PCMHs have been the major policy change associated with the increased use of advanced practice providers in CHCs, said Pittman.

"There's a whole movement around shared decision making that really has changed the way providers and patients interact with each other," said Martsolf.

What's more striking to her than the constellation of complex illnesses she helps manage, are the realities of lives in crises. "Medical care is only one piece of what people need," said Fattibene. Many need social workers, behavioral health workers, pharmacists, doctors, PAs and NPs – what Fattibene calls a "team." "In general," said Fattibene, "you could expect that people are moving toward understanding that no single provider can resolve all of the needs of patients with complex chronic diseases."

Nurse managed health centers (NMHCs), like the one Fattibene works at, are located in shortage areas and are managed by nurses many with advanced degrees. Defined in law in 2010, $ 14.8 million in federal prevention funds were provided to increase primary care access to fund NMHCs and were another example of enhanced use of NPs under the ACA.

According to Nancy De Leon Link, CEO of the National Nurse-Led Consortium, The Family Practice and Counseling Network in Philadelphia, one of the NMHCs to receive funding, uninsured rates dropped from 25% to 9%, which increased revenue and the capacity to meet the needs of newly insured individuals.

While studies are still pending regarding how the Medicaid expansion directly affected utilization, according to the National Association of Community Health Centers analysis of data, in 2010, 3,800 nurse practitioners provided 10.7 million visits and 2,000 PAs provided 6.3 million patient visits.

In 2015, 6,900 nurse practitioners provided 17.7 million visits and 2,800 PAs provided close to 8 million visits, exclusive of certified nurse midwife visits. In 2010, there were 1,124 CHCs. In 2015, there were 1,375. During this same period, physician employment by CHCs increased by about 24%, while NP employment increased by 81%.

The ACA also provided training grant programs including Graduate Nursing Education (GNE), increased funding for HPSAs, loan repayment programs and a demonstration grant for a 1-year residency training program for NPs in FQHCs.

In 2013, there were five GNE projects through the Center for Medicare and Medicaid Services (CMS), modeled after the Graduate Medical Education program.

The outcomes of the GNE programs are still being evaluated, but Barbara Todd, director of the GNE Demonstration Project at the Hospital University of Pennsylvania and senior fellow at the Center for Health Outcomes and Policy at the University of Pennsylvania School of Nursing said her program experienced a significant increase in graduates from 2012 to 2016. "From a school of nursing perspective, it increased my enrollment and [I can] be assured my students will have clinical training sites, because if they don't have clinical training sites they can't graduate because this is a practicing degree," said Todd.

In any case, those programs are targeted for cuts, which has many in the NP community concerned. On March 17, 2017, Cindy Cooke, president of the American Association of Nurse Practitioners released an online statement: "... we believe the proposed cuts of 20% to the US Department of Health and Human Services and the National Institutes of Health will undermine patient care by gutting vital training programs that strengthen the healthcare workforce."

Researchers at GWU predicted almost 1 million healthcare jobs could be lost in 2019, but Joseph Antos of the American Enterprise Institute disagreed, "I actually think that there is an opportunity for non-physician practitioners precisely because Republicans have basically put themselves under the gun to find ways to reduce the rapid growth of healthcare costs."

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